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Structures, Policies, SystemsLocal, state, federal policies and laws to
regulate/support healthy actions
InstitutionsRules, regulations, policies &
informal structures
CommunitySocial Networks, Norms, Standards
InterpersonalFamily, peers, social networks,
associations
IndividualKnowledge, attitudes,
beliefs
Levels of Influence in the Social-Ecological Model
Objectives
Students will be able to:• Identify advantages to increasing breastfeeding
rates in the population• List 2010 Healthy People goals for breastfeeding• Access population-based breastfeeding data
and describe patterns of breastfeeding in the US• Apply evidence-based approaches to improve
breastfeeding rates• Use knowledge about the physiology of
breastfeeding to advocate for policies that support breastfeeding
Benefits of Breastfeeding
• Health outcomes– Infant – short term– Infant – long term– Maternal
• Economic
• Environmental
Breastfeeding and Maternal and Infant
Health Outcomes in Developed Countries
(Agency for Healthcare Research and Quality, 2007)
• Systematic reviews/meta-analyses, randomized and non-randomized comparative trials, prospective cohort, and case-control studies on the effects of breastfeeding
• English language• Studies must have a comparative arm of formula
feeding or different durations of breastfeeding. Only studies conducted in developed countries were included in the updates of previous systematic reviews.
• Studies graded for methodological quality.
Limitations of Breastfeeding Outcome Studies
• Definitions of breastfeeding; misclassification
• Lack of randomization; confounding & residual confounding
• “Wide range in quality of evidence”
AHRQ: Positive Findings for Infants% less in BF
Acute otitis media (exclusive BF 3-6 mos.) 50%
Atopic dermatitis (exclusive BF 3 mos) 42%
GI infection (infants breastfeeding) 64%
Lower respiratory tract diseases 72%
Asthma (in young children) – no family hx, family hx 27%, 40%
Obesity 4, 7, 24%
Type I diabetes 19, 27%
Type 2 diabetes 39%
Childhood leukemia 15, 19%
Sudden Infant Death Syndrome 36%
Necrotizing enterocolitis 4-82%
AHRQ: Equivocal or insignificant infant outcomes
• Cognitive development in term or preterm infants
• CVD
• Infant mortality in developed countries
AHRQ: Positive Maternal Outcomes
% less in BF
Maternal Type II Diabetes (reduction in risk per year of lactation)
4, 12%
Postpartum depression association
Breast cancer (reduction per year of lactation)
4.3, 28%
Ovarian cancer 21%
AHRQ: Equivocal or insignificant maternal outcomes
• Effect of breastfeeding in mothers on return-to-pre-pregnancy weight was negligible
• Effect of breastfeeding on postpartum weight loss was unclear
• Little or no evidence for association with osteoporosis
Breastfeeding and Obesity: Reviews & Meta-analysis
• Owen et al. Pediatrics. 2005– 61 studies– Odds ratio = 0.87 (95% CI 0.85-0.89) for reduced
risk of later obesity associated with breastfeeding compared to formula
• Arenz et al. Int J obes relat metab disord. 2004– 9 studies met criteria– Odds Ratio = 0.78, 95% CI (0.71, 0.85) protective
effect of breastfeeding for obesity– Found dose response
• Harder et al. Am J Epidemiol. 2005
Breastfeeding and risk of obesity
Does Breastfeeding Reduce the Risk of Pediatric Overweight? CDC. 2007
Harder et al. Am J Epidemiol. 2005 (17 studies)
Length of Breastfeeding
Odds Ratio for Risk of Obesity
95% CI
< 1 1.00 0.65, 1.55
1-3 0.81 0.74, 0.88
4-6 0.76 0.67, 0.86
7-9 0.67 0.55, 0.82
9 0.68 0.50, 0.91
Breastfeeding & Obesity: Support for the Evidence
• Secular trends– Trend for increased breastfeeding is opposite that for obesity
• Dose Response– Some studies find, others do not
• Plausible mechanisms– Changes in leptin production and sensitivity– Lower energy and protein intake in breastfed infants– Insulin response to feeding; higher in formula fed infants– Differences in the feeding relationship; self-regulation of
energy intake– Changing composition of human milk during feedings
Dubois et al. Public Health Nutrition, 2003
• Social inequalities in infant feeding during the first year of life. The Longitudinal Study of Child Development in Quebec (LSCDQ 1998-2002)
• “Social disparities in diet during infancy could play a role in the development of social and health inequalities more broadly observed at the population level.”
Economic Costs of Formula Feeding(US Breastfeeding Committee)
• Families: ~$2,000 for the first year• Employers: loss of productivity, increased
absence, more health claims• Health care: 3.6 billion a year to treat
infant illnesses, $331-475 per child for one HMO
• Food assistance: costs to support breastfeeding mothers in WIC are 55% the cost for providing formula
Environmental Benefits of Breastfeeding
(ADA Position Paper, 2005)
• Human milk is a renewable natural resource.• Produced and delivered to the consumer directly• Formula requires manufacturing, packaging,
shipping, disposing of containers– 550 million formula cans in landfills each year*– 110 billion BTUs of energy to process and transport*
• Breastfeeding delays return of menses, increases birth spacing, limits population growth
• Note ADA position statement 2009 – environmental benefits not included…..
*USBC
Barriers to Breastfeeding (ADA Position Paper 2005)
• Individual: Inadequate knowledge, embarrassment, social reticence, negative perceptions
• Interpersonal: Lack of support from partner and family, perceived threat to father-child bond
• Institutional: Return to work or school, lack of workplace facilities, unsupportive health care environments
• Community: discomfort about nursing in public• Policy: aggressive marketing by formula
companies
2007 Health Styles Survey
Question AgreeNeither
Agree/Disagree
Disagree
Mothers who breastfeed should do so in private places only.
35.8% 26.0% 38.2%
I am comfortable when mothers breastfeed their babies near me in a public place, such as a shopping center, bus station, etc.
44.1% 24.6% 31.3%
I believe women should have the right to breastfeed in public places.
52.0% 23.8% 24.2%
Infant formula is as good as breast milk.
20.2% 27.2% 52.6%
National Immunization Survey
• Random-digit--dialed telephone survey conducted annually by CDC
• Nationally representative data
• Breastfeeding questions first added in 2001
• Data organized by birth cohort, not year of data gathering
• 2004 data from 17,654 infants
Healthy People 2010: Increase the proportion of mothers who breastfeed their
babiesGoal US
Base-line
WA
2004
WA 2005 WA 2006 WA 2007
Early post-partum
75% 64% 88% 90% 86% 88%
At 6 months
50% 25% 57% 57% 58% 60%
At one year
25% 16% 32% 33% 35% 33%
Percent of U.S. children who were breastfed, by birth year
Breastfeeding Among U.S. Children Born 1999—2008, CDC National Immunization Survey
Provisional Rates of Any and Exclusive Breastfeeding by Age among Children Born
in 2008, National Immunization Survey
New 2010 Breastfeeding Objectives added in 2007
• To increase the proportion of mothers who exclusively breastfeed their infants through age 3 months to 60%
• To increase the proportion of mothers who exclusively breastfeed their infants through age 6 months to 25%
Exclusive breastfeeding: definition
• Exclusive breastfeeding is defined as an infant receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines
Exclusive BreastfeedingUS
2004
US
2005
US 2006
US 2007
WA
2004
WA 2005
WA 2006
WA 2007
Through 3 months
31 36 33 33 50 45 49 44
Through 6 months
11 12 14 13 23 21 25 21
Rates of Exclusive Breastfeeding at 3 months (NIS, 2004)
Maternal Education %
Less than high school 24
High school 23
Some college 33
College graduate 42
Income/poverty ratio
< 100 24
100 - 184 29
185 - 340 34
>350 39
Rates of Exclusive Breastfeeding at 3 months (NIS, 2004)
Education %
Hispanic 31
White, non-Hispanic 33
Black, non-Hispanic 20
Asian, non-Hispanic 31
Other
Mother’s age at birth of child
< 20 17
20-29 26
> 30 35
Percent of Children Exclusively Breastfed Through 3 Months of Age among Children born
National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services
20052007
Healthy People 2020; 2011 Report Card (2008 births)
Goal National WA State
Ever Breastfed
82 75 89
At 6 months
61 44 60
At 12 months
34 24 35
Exclusive at 3 months
46 35 49
Exclusive at 6 months
26 15 23
Formula before 2 days
14 25 18
Six evidence-based interventions
• Individual: – Educating mothers– Professional support
• Intrapersonal:– Peer support/counseling programs
• Institutional – Maternity care practices
• Media and social marketing
Four Interventions: Effectiveness not established, encourage rigorous evaluation
1. Use contermarketing techniques to limit the negative impact of formula marketing
2. Improve the knowledge, skills and attitudes of health care providers re breastfeeding
3. Increase public acceptance of breastfeeding
4. Provide assistance to breastfeeding mothers through hotlines or other information sources
Breastfeeding Policy Documents1984 U.S. Surgeon General’s Workshop
1990 Innocenti Declaration, WHO and UNICEF
2000 HHS Blueprint for Action on Breastfeeding
2001 US Breastfeeding Committee Strategic Plan
2003 WHO: Global Strategy for Infant and Young Child Feeding
2010 Breastfeeding A Vision for the Future (USBC & others)
2011 Surgeon General’s “Call to Action to Support Breastfeeding”
The Surgeon General’s Call to Action to Support Breastfeeding
Actions for Mothers and Their Families: 1. Give mothers the support they need to breastfeed their babies.
2. Develop programs to educate fathers and grandmothers about breastfeeding.
Actions for Communities: 3. Strengthen programs that provide mother-to-mother support and peer counseling.
4. Use community-based organizations to promote and support breastfeeding.
5. Create a national campaign to promote breastfeeding.
6. Ensure that the marketing of infant formula is conducted in a way that minimizes its negative impacts on exclusive breastfeeding
The Surgeon General’s Call to Action to Support Breastfeeding
Actions for Employment: 13. Work toward establishing paid maternity leave for all employed mothers.
14. Ensure that employers establish and maintain comprehensive, high-quality lactation support programs for their employees.
15. Expand the use of programs in the workplace that allow lactating mothers to have direct access to their babies.
16. Ensure that all child care providers accommodate the needs of breastfeeding mothers and infants.
Worksites
Global Strategy for Infant & Young Child Feeding
WHO/ UNICEF (2003)
Innocenti Declaration WHO/ UNICEF (1990)
“Women in paid employment can be helped to continue breastfeeding by bring provided with minimal enabling conditions. paid maternity leave, part- time work arrangements, onsite crèches, facilities for expressing and storing breastmilk and breastfeeding breaks.”
“…obstacles to breastfeeding within the…workplace…
must be eliminated…”
HHS Blueprint: Worksites
1. “Facilitate breastfeeding or breastmilk expression at the workplace by providing private rooms, commercial grade breastpumps, milk storage arrangements, adequate breaks during the day, flexible work schedules and onsite childcare facilities.”
2. “Establish family and community programs that enable breastfeeding continuation when women return to work in all possible settings.”
3. “Encourage childcare facilities to provide quality breastfeeding support.”
CDC Healthstyle Survey (Nationally
representative postal survey N~5000)
Agree 2006
Agree 2009
I believe employers should provide flexible work schedules, such as additional break time, for breastfeeding mothers
51 56
I believe employers should provide extended maternity leave to make it easier for mothers to breastfeed.
49 47
Healthstyle Survey, cont.
Agree 2006
Agree 2009
I believe employers should provide a private room for breastfeeding mothers to pump their milk at work.
47 46
I would support tax incentives for employers who make special accommodations to make it easier for mothers to breastfeed.
30 25
WA Healthy Worksite Survey• Content: Measures policies, & environments to support
healthy nutrition, physical activity, breastfeeding and to discourage tobacco use.
• Population: WA businesses with 50+ employees, selected from WA Department of Employment Security.
• Sampling: Representative geographic sample across WA. 900 contacted, 540 responded.
• Administration: Fall 2005. 15 minute phone survey of HR managers, conducted by Gilmore. Repeat in 2007.
• Background: DOH STEPS/CDNPA/Tobacco collaboration
Of the 400 Businesses with Female Employees < age of 50:
• 11% had a specific policy to support breastfeeding
• 82% provided flexible scheduling to allow employees adequate break time to breastfeed or pump/express breast milk
• 31% had a designated room or location (not counting bathroom stalls) for mothers to breastfeed or pump/express breast milk
Amenities Located in Breastfeeding Rooms
0% 20% 40% 60% 80% 100%
Locking door for privacy
Electrical outlet
Handwashing sink
Refrigerator to storepumped/expressed milk
Characteristics of Breastfeeding Rooms
Key Policy Documents: Childcare
HHS Blueprint for Action (2000)
WA State Nutrition & Physical
Activity Plan
(2003)
•Safe storage•Follow mothers’ instructions•Provide quiet and comfortable place for mothers
•“Assure that…child care facilities are breastfeeding friendly.”•Follow guidelines of Breastfeeding coalition of Washington.
The Surgeon General’s Call to Action to Support Breastfeeding
Actions for Health Care: 7. Ensure that maternity care practices around the United States are fully supportive of breastfeeding.
8. Develop systems to guarantee continuity of skilled support for lactation between hospitals and health care settings in the community.
9. Provide education and training in breastfeeding for all health professionals who care for women and children.
10. Include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians.
11. Ensure access to services provided by International Board Certified Lactation Consultants.
12. Identify and address obstacles to greater availability of safe banked donor milk for fragile infants.
Key Policy Documents: Health Care
Global Strategy for Infant & Young Child Feeding
WHO/ UNICEF (2003)
WA State Nutrition & Physical Activity Plan
(2003)
“Virtually all mothers can breastfeed provided they have accurate information, and support within their families and communities and from the health care system. They should also have access to skilled practical help from, for example, trained health workers, lay and peer counselors, and certified lactation consultants…”
•Support King County model breastfeeding standards.
Key Policy Documents: Health CareInternational Code of
Marketing of Breastmilk Substitutes
WHO (1981)
Innocenti Declaration
WHO/ UNICEF(1990)
“No facility of a health care system should be used for the purpose of promoting infant formula or other products…”
“Health workers should encourage and protect breastfeeding…”
“…obstacles to breastfeeding within the…health system…must be eliminated…”
“…every facility providing maternity services fully practices all ten of the Ten Steps to Successful Breastfeeding…”
HHS Blueprint: Health Care System
1. Train health care providers who provide maternal and child care on the basics of lactation, breastfeeding counseling and lactation management during coursework, clinical and in-service training and continuing education.”
2. Ensure that breastfeeding mothers have access to comprehensive, up-to-date, and culturally tailored lactation services provided by trained physicians, nurses, lactation consultants and nutritionists/dietitians.
Health Care System, cont.
3. Establish hospital and maternity center practices that promote breastfeeding, such as the “Ten Steps to Successful Breastfeeding.”
4. Develop breastfeeding education for women, their partners, and other significant family members during the prenatal and postnatal visits.
National Survey of Maternity Care Practices in Infant Nutrition and Care (mPINC)
• 2,546 hospitals, 121 birth centers in the 50 states, DC, Puerto Rico
• 35 questions; 7 categories – labor and delivery, – breastfeeding assistance, – mother-newborn contact, – newborn feeding practices, – breastfeeding support after discharge, – nurse/birth attendant breastfeeding training and
education, – structural and organizational factors related to
breastfeeding MMWR. June 13, 2008 / 57(23);621-625
FIGURE. Percentage of hospitals that implemented recommended maternity care practices related to breastfeeding* --- Maternity Practices in Infant Nutrition and Care Survey (mPINC), United States, 2007 and 2009
Recommended maternity care practices are indicators of the Ten Steps to Successful Breastfeeding
MMWR, August 5, 2011 / 60(30);1020-1025
mPINC Indicator 2007 (%)
2009 (%)
1. Model breastfeeding policy: hospital has a written breastfeeding policy that includes 10 model policy elements§
11.7 14.4
2. Staff competency assessment: nurses/birth attendants are assessed for competency in basic breastfeeding management and support at least once per year
44.6 49.7
3. Prenatal breastfeeding education: breastfeeding education is included as a routine element of prenatal classes
92.5 92.8
4. Early initiation of breastfeeding: ≥90% of healthy full-term breastfed infants initiate breastfeeding within one hour of uncomplicated vaginal birth
43.5 50.9
5. Teach breastfeeding techniques: ≥90% of mothers who are breastfeeding or intend to breastfeed are taught breastfeeding techniques (e.g., positioning, how to express milk, etc.)
87.8 89.1
Maternity Practices in Infant Nutrition and Care (mPINC)
(2,690 hospital & birth facilities participated; 2,672 facilities participated in 2009; based on Ten Steps to Successful Breastfeeding; MMWR, August 5, 2011 / 60(30);1020-1025 )
mPINC Indicator 2007 (%)
2009 (%)
6. Limited use of breastfeeding supplements: <10% of healthy full-term breastfed infants are supplemented with formula, glucose water, or water
20.6 21.5
7. Rooming-in: ≥90% of healthy full-term infants, regardless of feeding method, remain with their mother for at least 23 hours per day during the hospital stay
30.8 33.2
8. Teach feeding cues: ≥90% of mothers are taught to recognize and respond to infant feeding cues instead of feeding on a set schedule
77.0 81.8
9. Limited use of pacifiers: <10% of healthy full-term breastfed infants are given pacifiers by maternity care staff members
25.3 30.1
10. Post-discharge support: hospital routinely provides three modes of post-discharge support to breastfeeding mothers: physical contact, active reaching out, and referrals¶
26.8 26.8
State Breastfeeding Legislation
• Breastfeeding in public: 23 states give the right to breastfeed in any place it is legal to be
• Jury duty: 7 states exempt breastfeeding mothers from jury duty
• Family law: three states require breastfeeding status to be considered in divorce or custody decisions.
WA Breastfeeding Legislation
1. Amendment to indecent exposure law– “A person is guilty of indecent exposure if he
or she intentionally makes any open and obscene exposure of his or her person or the person of another knowing that such conduce is likely to cause reasonable affront or alarm. The act of breastfeeding or expressing breast milk is not indecent exposure.”
WA breastfeeding legislation
• “Am employer may use the designation “ infant friendly” on its promotional materials if the employer has an approved workplace breastfeeding policy addressing at least the following:– Flexible work schedule, place to nurse/express with
handwashing facilities and refrigerator
• DOH to approve employers, but no funds to do this, so no worksites have been designated
HB 1596 - 2009
• An act relating to protecting a woman’s right to breastfeed in a place of public resort, accommodation, assemblage, or amusement; amending RCW 49.60.030 and 49.60.215.
• Adds breastfeeding to rights protecting discrimination because or race, creed, color, national origin, sex, honorably discharged veteran, sexual orientation or the presence of….disability..
CDC Breastfeeding Report Card 2009 – Process Indicators
US WA
Percent of live births occurring at facilities designated as Baby Friendly (BFHI)
2.87 6.85
Number of IBCLCs ** per 1000 live births
2.20 4.16
Number of state health dept FTEs dedicated to breastfeeding
80 1.4
CDC Report Card, cont.
US WA
State legislation about breastfeeding in public places
46 yes
State legislation mandating employer support
15 no
Presence of an active statewide breastfeeding coalition
41 yes
The Surgeon General’s Call to Action to Support Breastfeeding
Actions for Research and Surveillance: 17. Increase funding of high-quality research on breastfeeding.
18. Strengthen existing capacity and develop future capacity for conducting research on breastfeeding.
19. Develop a national monitoring system to improve the tracking of breastfeeding rates as well as the policies and environmental factors that affect breastfeeding.
Action for Public Health Infrastructure: 20. Improve national leadership on the promotion and support of breastfeeding.
A Vision for the Future
• We look forward to a society where:
• There is widespread knowledge of the importance of breastfeeding and the risks of not breastfeeding.
• Mothers and families make informed choices about feeding children.
• Women begin and continue to breastfeed for as long as they wish.
http://org2.democracyinaction.org/o/5162/p/dia/action/public/?action_KEY=4610
1. Meet and exceed the Healthy People objectives to increase the proportion of mothers who breastfeed.
2. Implement maternity care practices that foster normal birth and breastfeeding in every facility that cares for childbearing women.
3. Ensure that health care providers provide evidence-based, culturally competent birth and breastfeeding care.
4. Create and foster work environments that support breastfeeding mothers.
5. Ensure that all federal, state, and local laws relating to child welfare and family law recognize the importance of breastfeeding and support its practice.
6. Implement curricula that teach students of all ages that breastfeeding is the normal and preferred method of feeding infants and young children.
7. Reduce the barriers to breastfeeding imposed by the marketing of human milk substitutes.
8. Protect a woman’s right to breastfeed in public.
9. Encourage greater social support for breastfeeding as a vital public health strategy.